dawnmedDawnMed Journal of Medical ScienceISVolume 2, Issue 3MultidisciplinaryEnglish2026NNY20260811General SurgeryMinimally Invasive Surgery for Ankle and Distal Tibial Fractures: A Narrative ReviewEnglishY4049Abdulrahman M.Alquraynis¹EnglishNAbdullah KhalidAbusoliman²EnglishYAbdullah Nasser A.Almawash³EnglishYOmar Sami A.Alzamil⁴EnglishYBassam Khalifah S.Alkhalifah⁵EnglishYSultan Mohammed A.Alali⁶EnglishYAbdulmalik Ahmed N.Alomrani³EnglishYAbdullah Fahad S.Alkhalifah⁵EnglishYHamoud Sultan M.Albaqami⁷EnglishYLuay Musaad A.Almutair³EnglishYAbdulwahab Ali A.Albakri⁶EnglishYSuliman Ahmed S.Alluhib²EnglishYAhmed Abdullah A.Alzahrani⁴EnglishYFahad SaudAlsubaie⁸EnglishYSultan Amjad A.Alzamil⁷EnglishY10.64039/djms.2026.2304Minimally invasive fixation is used to reduce surgical disruption of the soft-tissue envelope around ankle and distal-tibial fractures. This narrative review examines distal-fibular minimally invasive plate osteosynthesis, distal-tibial minimally invasive plate osteosynthesis and fibular intramedullary nailing, with intra-articular pilon fractures considered separately from extra-articular metaphyseal injuries.Minimally invasive surgery is not a single intervention. The reviewed evidence supports lower wound morbidity with some fibular-nail and limited-plating protocols, but it does not establish general functional equivalence or superiority. Existing syntheses overlap in their primary studies and combine different devices and patient groups. Distinct healing, reduction and reoperation endpoints should remain separate.Limited exposure increases the importance of confirming length, coronal and sagittal alignment, axial rotation and syndesmotic position. The reviewed distal-tibial evidence does not define a safe malrotation threshold. Conventional radiography and fluoroscopy can miss syndesmotic displacement, while CT classification is itself sensitive to landmarks, thresholds and side-to-side variation. The association between syndesmotic malreduction and function remains unresolved.The average short-term wound-infection risk after ankle ORIF is low, so the soft-tissue rationale for minimally invasive fixation is strongest in selected patients with compromised tissue or medical risk. Direct comparative evidence in these high-risk groups remains limited. Technique selection should be based on fracture morphology, soft-tissue condition and the ability to obtain and verify reduction. Future trials should use contemporary implants, preserve randomized allocation in analysis, separate fracture populations and report prespecified functional, radiological and complication outcomes. Multicentre comparative research should document technical failures, crossovers, conversions to open fixation and surgeon experience.Englishankle fractures, distal tibial fractures, minimally invasive plate osteosynthesis, fibular intramedullary nailing, syndesmosis; malrotationhttps://dawnmed.com.sa/abstract?id=27References1619Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures.and;nbsp;Foot Ankle Surg.and;nbsp;2018;24(1):34and;ndash;39.and;nbsp;doi:10.1016/j.fas.2016.11.002.Gundtoft PH, Pedersen AB, Viberg B. Incidence, treatment, and mortality of ankle fractures: a Danish population-based cohort study.and;nbsp;Acta Orthop.and;nbsp;2025;96:203and;ndash;208.and;nbsp;doi:10.2340/17453674.2025.43006.Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift.and;nbsp;J Bone Joint Surg Am.and;nbsp;1976;58(3):356and;ndash;357.and;nbsp;doi:10.2106/00004623-197658030-00010.Lloyd J, Elsayed S, Hariharan K, Tanaka H. Revisiting the concept of talar shift in ankle fractures.and;nbsp;Foot Ankle Int.and;nbsp;2006;27(10):793and;ndash;796.and;nbsp;doi:10.1177/107110070602701006.Kurt E, Demir T, Tekşan E, Karaca H, Aytekin K. The minimally invasive approach for lateral malleolus fractures plating demonstrating less pain, shorter operative time and earlier discharge compared to open approach: a prospective randomized controlled trial.and;nbsp;J Orthop Surg Res.and;nbsp;2026;21:125.and;nbsp;doi:10.1186/s13018-025-06624-z.SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures.and;nbsp;J Bone Joint Surg Am.and;nbsp;2009;91(5):1042and;ndash;1049.and;nbsp;doi:10.2106/JBJS.H.00653.Miller AG, Margules A, Raikin SM. Risk factors for wound complications after ankle fracture surgery.and;nbsp;J Bone Joint Surg Am.and;nbsp;2012;94(22):2047and;ndash;2052.and;nbsp;doi:10.2106/JBJS.K.01088.Hassaan AM, Hassan AA, Abdelkhalik WS, et al. Efficacy and safety of MIPO versus ORIF in distal tibial fractures: a systematic review and meta-analysis.and;nbsp;J Orthop Traumatol.and;nbsp;2026;27:30.and;nbsp;doi:10.1186/s10195-026-00938-2.Lau TW, Leung F, Chan CF, Chow SP. Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures.and;nbsp;Int Orthop.and;nbsp;2008;32(5):697and;ndash;703.and;nbsp;doi:10.1007/s00264-007-0384-z.Daniels NF, Lim JA, Thahir A, Krkovic M. Open pilon fracture postoperative outcomes with definitive surgical management options: a systematic review and meta-analysis.and;nbsp;Arch Bone Jt Surg.and;nbsp;2021;9(3):272and;ndash;282.and;nbsp;doi:10.22038/abjs.2020.53240.2641.Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures.and;nbsp;J Orthop Trauma.and;nbsp;1999;13(2):78and;ndash;84.and;nbsp;doi:10.1097/00005131-199902000-00002.Marazzi C, Wittauer M, Hirschmann MT, Testa EA. Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures.and;nbsp;J Orthop Surg Res.and;nbsp;2020;15:491.and;nbsp;doi:10.1186/s13018-020-02018-5.Yaand;ntilde;ez Arauz JM. Minimally invasive treatment of AO B ankle fractures: surgical technique and long-term outcomes.and;nbsp;Foot Ankle Surg.and;nbsp;2021;27(7):742and;ndash;749.and;nbsp;doi:10.1016/j.fas.2020.09.010.Akdemir M, Turan AC, Tand;uuml;rken MA, Biand;ccedil;en and;Ccedil;, Kilic AI. Comparison of open reduction and internal fixation with minimally invasive plate osteosynthesis in distal tibial fractures.and;nbsp;Cureus.and;nbsp;2022;14(3):e23144.and;nbsp;doi:10.7759/cureus.23144.White TO, Bugler KE, Olsen L, Lundholm LH, Holck K, Madsen BL, Duckworth AD. A prospective randomized controlled two-centre international trial comparing the fibular nail with open reduction and internal fixation for unstable ankle fractures in younger patients.and;nbsp;J Orthop Trauma.and;nbsp;2022;36(1):36and;ndash;42.and;nbsp;doi:10.1097/BOT.0000000000002140.Ricketts C, et al. Ankle fractures treated with locked fibular intramedullary nailing.and;nbsp;J Orthop Trauma.and;nbsp;2025;39(1):1and;ndash;7.and;nbsp;doi:10.1097/BOT.0000000000002908.Erivan R, Caputo T, Monadjemi S, Pereira B, Descamps S, Boisgard S, Villatte G. Minimally invasive plate osteosynthesis versus open reduction and internal fixation for pilon fractures: a prospective randomized study.and;nbsp;Orthop Traumatol Surg Res.and;nbsp;2025;111(7):104323.and;nbsp;doi:10.1016/j.otsr.2025.104323.Shaner AC, Sirisreetreerux N, Shafiq B, Jones LC, Hasenboehler EA. Open versus minimally invasive fixation of a simulated syndesmotic injury in a cadaver model.and;nbsp;J Orthop Surg Res.and;nbsp;2017;12:160.and;nbsp;doi:10.1186/s13018-017-0658-0.Bastand;iacute;as GF, Bravo F, Astudillo C, et al. Restoration of anatomic parameters and syndesmotic reduction after intramedullary nailing of distal fibular fractures.and;nbsp;Foot Ankle Orthop.and;nbsp;2022;7(4):24730114221141388.and;nbsp;doi:10.1177/24730114221141388.Asloum Y, Bedin B, Roger T, Charissoux JL, Arnaud JP, Mabit C. Internal fixation of the fibula in ankle fractures: a prospective, randomized and comparative studyand;mdash;plating versus nailing.and;nbsp;Orthop Traumatol Surg Res.and;nbsp;2014;100(4 Suppl):S255and;ndash;S259.and;nbsp;doi:10.1016/j.otsr.2014.03.005.White TO, Bugler KE, Appleton P, Will E, McQueen MM, Court-Brown CM. A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients.and;nbsp;Bone Joint J.and;nbsp;2016;98-B(9):1248and;ndash;1252.and;nbsp;doi:10.1302/0301-620X.98B9.35837.Tas DB, Smeeing DPJ, Emmink BL, et al. Intramedullary fixation versus plate fixation of distal fibular fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies.and;nbsp;J Foot Ankle Surg.and;nbsp;2019;58(1):119and;ndash;126.and;nbsp;doi:10.1053/j.jfas.2018.08.028.Jain S, Haughton BA, Brew C. Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes.and;nbsp;J Orthop Traumatol.and;nbsp;2014;15(4):245and;ndash;254.and;nbsp;doi:10.1007/s10195-014-0320-0.Zhang J, Luo R, Chen J. The fibular intramedullary nail versus plate fixation for ankle fractures in adults: a systematic review and meta-analysis of randomized controlled trials.and;nbsp;J Orthop Surg Res.and;nbsp;2024;19:542.and;nbsp;doi:10.1186/s13018-024-05032-z.Liu XK, Xu WN, Xue QY, Liang QW. Intramedullary nailing versus minimally invasive plate osteosynthesis for distal tibial fractures: a systematic review and meta-analysis.and;nbsp;Orthop Surg.and;nbsp;2019;11(6):954and;ndash;965.and;nbsp;doi:10.1111/os.12575.Zhang J, Liu H, Xu W, et al. Effect of tibial rotation on knee and ankle function after minimally invasive plate osteosynthesis.and;nbsp;Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.and;nbsp;2024;38(10):1236and;ndash;1243.and;nbsp;doi:10.7507/1002-1892.202404041.and;Ccedil;epni S, Yaman F, Veizi E, Firat A, and;Ccedil;ay N, Tecimel O. Does malrotation following MIPO treatment of distal tibia metaphyseal fractures affect functional results?and;nbsp;J Orthop Trauma.and;nbsp;2021;35(9):492and;ndash;498.and;nbsp;doi:10.1097/BOT.0000000000002053.Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures.and;nbsp;Foot Ankle Int.and;nbsp;2006;27(10):788and;ndash;792.and;nbsp;doi:10.1177/107110070602701005.Marmor M, Hansen E, Han HK, Buckley J, Matityahu A. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model.and;nbsp;Foot Ankle Int.and;nbsp;2011;32(6):616and;ndash;622.and;nbsp;doi:10.3113/FAI.2011.0616.Franke J, von Recum J, Suda AJ, Grand;uuml;tzner PA, Wendl K. Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries.and;nbsp;J Bone Joint Surg Am.and;nbsp;2012;94(15):1386and;ndash;1390.and;nbsp;doi:10.2106/JBJS.K.01122.Cunningham BA, Warner SJ, Berkes MB, et al. Effect of intraoperative multidimensional fluoroscopy versus conventional fluoroscopy on syndesmotic reduction.and;nbsp;Foot Ankle Int.and;nbsp;2021;42(2):132and;ndash;136.and;nbsp;doi:10.1177/1071100720959025.Davidovitch RI, Weil Y, Karia R, et al. Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging.and;nbsp;J Bone Joint Surg Am.and;nbsp;2013;95(20):1838and;ndash;1843.and;nbsp;doi:10.2106/JBJS.L.00382.Kubik JF, Rollick NC, Bear J, et al. Assessment of malreduction standards for the syndesmosis in bilateral CT scans of uninjured ankles.and;nbsp;Bone Joint J.and;nbsp;2021;103-B(1):178and;ndash;183.and;nbsp;doi:10.1302/0301-620X.103B1.BJJ-2020-0844.R1.Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up.and;nbsp;J Orthop Trauma.and;nbsp;2012;26(7):439and;ndash;443.and;nbsp;doi:10.1097/BOT.0b013e31822a526a.Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures.and;nbsp;J Orthop Trauma.and;nbsp;2005;19(2):102and;ndash;108.and;nbsp;doi:10.1097/00005131-200502000-00006.Warner SJ, Fabricant PD, Garner MR, et al. The measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures.and;nbsp;J Bone Joint Surg Am.and;nbsp;2015;97(23):1935and;ndash;1944.and;nbsp;doi:10.2106/JBJS.O.00016.Cherney SM, Cosgrove CT, Spraggs-Hughes AG, et al. Functional outcomes of syndesmotic injuries based on objective reduction accuracy at a minimum 1-year follow-up.and;nbsp;J Orthop Trauma.and;nbsp;2018;32(1):43and;ndash;51.and;nbsp;doi:10.1097/BOT.0000000000001000.Oand;rsquo;Brien AC, Puleo JM, Mener A, Rosenbaum A, Chisena EN. Postoperative syndesmotic widening following ankle fracture fixation: a retrospective comparison of fibular nailing and plating.and;nbsp;Orthopedics.and;nbsp;2026;49(1):e39and;ndash;e46.and;nbsp;doi:10.3928/01477447-20251210-04.Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes.and;nbsp;Foot Ankle Int.and;nbsp;2011;32(2):120and;ndash;130.and;nbsp;doi:10.3113/FAI.2011.0120.Band;auml;cker HC, Vosseller JT. Fibula fracture: plate versus nail fixation.and;nbsp;Clin Orthop Surg.and;nbsp;2020;12(4):529and;ndash;534.and;nbsp;doi:10.4055/cios19177.